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THE ELUSIVE POST CONCUSSIVE SYNDROME:
by TERRY G. SHAW, Ph.D., A.B.P.N.

People involved in an accident in which they sustain a seemingly minor injury to the head (ranging from whiplash to concussion) may subsequently develop a variety of emotional and physical problems. For example, they may complain of memory problems, headache, insomnia, blurred vision, difficulty with concentration, ringing in the ears, irritability, anxiety, depression, fatigue, dizziness, confusion and sensitivity to light and noise. The regularity of this symptom picture has subsequently led to the use of Post Concussive Syndrome (PCS) as an explanatory medical diagnosis.

Unfortunately, a diagnosis of PCS can be misleading. For example, some clinicians believe that PCS symptoms following any kind of an accident are indications of underlying brain injury. It is true that most if not all patients who suffer a mild brain injury will display many of the PCS symptoms. However, the reverse is not always true. The presence of PCS symptoms after a trauma is not a definitive sign of traumatic brain injury. In fact, recent studies reveal that PCS symptoms are equally present in a variety of non-brain damaged populations ranging from college students to patients undergoing litigation for non-injury related reasons. The research goes on to suggest that stress (or how people respond to stress) plays a more important role in the development of PCS symptoms.

Survey of the literature currently suggests that any one of five different disorders can be lumped into the PCS diagnostic category. These include; 1) mild TBI with poor psychological adjustment; 2) stress related reactions such as Post Traumatic Stress Disorder; 3) somatoform or "conversion" disorders; 4) cervical-adnexal or musculoligamentous injuries; and 5) malingering. Given the overlapping symptom picture for each of these, many clinicians have turned to neuropsychologist tests to tease apart these disorders. Unfortunately, neuropsychological test scores do not always help. The effects of stress (which seem to be at the heart of the PCS symptom picture) also cause "uneven" or inconsistent neuropsychological test performance and there appears to be no unique pattern of cognitive strengths and weaknesses associated with any of these disorders. Nevertheless, through a combination of history, clinical presentation and careful analysis of the data some clarification is possible. Furthermore, distinguishing between these different disorders is critical to providing patients with the correct form of treatment. With that in mind, I offer the following discussion of each disorder.

Mild Traumatic Brain Injury With Poor Adjustment

When a person receives a blow to the head sufficient to result in brief loss of consciousness and/or brief confusion and amnesia for the event, mild traumatic brain injury is (by definition) present. These patients will usually develop a number of symptoms that overlap the PCS symptom picture. But the literature is also becoming quite clear that only in rare instances do these symptoms last longer than 6 months. When someone with a history of mild TBI continues to have problems 6 months after the accident, chances are the symptoms are being perpetuated by faulty psychological adjustment to the injury. These psychologic reactions seem neither willful nor calculated and patients don't often understand why they have problems, especially when their physician has reassured them there is nothing wrong. They may even think they are "going crazy". As their anxiety and depression deepen, more cognitive deficits occur which in turn leads to a cycle of deepening depression and additional cognitive failures.

The reason why some patients recover without any problems while others have persistent problems seems to lie in the psychological makeup of the individual being injured. Those who don't adjust well may possibly have a history of earlier trauma, a persistent mood disorder, a history of substance abuse or a history of lifelong struggles and marginal coping skills. There is even recent evidence that genetics may play a role. In any event, the "person" involved in the accident may be as important to the outcome as the nature of the accident itself. The most effective from of treament seems to be educating victims about the effects of mild TBI and psychologically helping them re-instill more effective coping strategies. Pharmacology to treat the anxiety and depression is also helpful. The earlier intervention is provided, the more rapid the recover.

Stress Related Reactions

Sometimes when individuals are involved in traumatic accidents, their initial psychologic reaction to a life threatening event sets into motion a cascade of stress related responses known as Post Traumatic Stress Disorder (PTSD). These patients also exhibit an array of symptoms that overlap with PCS but the cause of their problems is related to a "learned" anxiety disorder or fear reaction associated with the original traumatic event. The learning occurs on a subconscious level and they are not aware that any learning took place yet they display vivid anxiety reactions when confronted by events or items that remind them of the original accident. They are sometimes confused with patients who have mild traumatic brain injury because they exhibit gaps in recall of events surrounding the accident but there is usually no loss of consciousness. In fact, patients with PTSD usually have poignantly clear recall of their initial fear and they often report they felt that they were going to "die".

Patients with PTSD are usually haunted by the accident in one or two ways. While they are awake, they may experience flashbacks of the trauma. When they are asleep, they may experience nightmares or wake up with nightsweats. They also avoid anything that resembles the original accident including a reluctance to even talk about the accident, go by the scene of the accident or even get out in public. As a result, they become increasingly withdrawn. The biochemical effects of their deep-seated anxiety also result in problems with attention, memory and personality changes which also lead clinicians to misdiagnose them as having a mild TBI but their symptoms arise from an entirely different source.

Treatment of PTSD is fairly effective if provided early and by a therapist who specializes in treating this disorder (ex., training in "psychotraumatology"). Traditional psychotherapy and educational efforts like the ones used to treat mild TBI patients are generally ineffective with this population and may actually cause a worsening of the condition. Medication at times can help but is rarely effective by itself.

Cervical-Adnexal Injuries

Sometimes when someone is involved in an accident, the primary injury is restricted to damage to the ligaments, muscles and connective tissue of the neck and upper extremities (eg. Cervical-Adnexal). This type of injury frequently sets into motion a dysfunctional pain response where the initial pain severely limits the persons ability to function. As the pain persists, limitations accumulate and depression and anxiety emerge. As a result of their emotional responses, cognitive impairments become apparent and this usually leads to an increase in tension and stress which then exacerbates the pain (e.g., psychogenic pain). Often these patients spiral downward emotionally, physically and cognitively as limitations accumulate. Obviously, this symptom picture has many similarities to PCS but the etiology of these symptoms occurs as a result of chronic pain rather than brain injury.

Diagnosis is usually made by x-rays, scans and electrophysiological data designed to reveal structural injury. Unfortunately, soft tissue injuries to the muscles or ligaments are sometimes hard to identify and in the absence of positive findings, patients are sometimes misdiagnosed. While a diagnostic label of PCS may seem to fit their complaints, rarely does it address the cause of their difficulties and the true nature of their injury may remain unappreciated until positive medical findings emerge.

Treatment of these patients usually includes massage, heat, manipulation and pharmacologic control for pain and inflammation. More involved treatment may include injections, use of electrical instruments designed to block or control pain and possibly participation in a formal pain clinic or outpatient pain program. Sometimes, depending upon the extent of the injury, surgery is required but this is usually the last resort.

Somatoform Disorders

For reasons that are not always clear, when certain individuals are injured in an accident, they go on to develop sensory, motor and/or cognitive problems that persist in the absence of objective clinical evidence of any injury. More often than not, their symptoms don't correspond to the known anatomy of the nervous system and despite apparent limitations, they usually don't seem to be worried about their disorder. In these cases, Freudian interpretations suggest that the patient has "converted" pre-existing stress and conflict into physical symptoms as a psychological maneuver designed to resolve an unrelated conflict or problem. Behavioral theories contend that the appearance of injury related deficits result in the patient being able to "escape" pre-existing conflict or stress and the symptoms persist simply as a means of allowing the person to continue to avoid dealing with the underlying problems.

Diagnosis is usually achieved through a process of elimination (e.g., ruling out other explanations). This usually culminates in psychological assessment designed to identify underlying issues that might be perpetuating the disorder. Treatment of this disorder also requires psychologic or psychiatric intervention and may necessitate pharmacologic treatment as well. The focus of treatment invariably involves helping the person become aware of their underlying emotional conflicts and teaching them new (and healthier) coping skills to resolve internal strife and conflict.

Malingering Disorder

Sometimes an individual is involved in an accident and for personal reasons, they choose to fabricate cognitive and/or physical deficits to the point that they become more impaired than would ordinarily be expected. Their behavior is invariably motivated by secondary gain which is usually (but not necessarily) financial and their symptoms often persist despite the best treatment. These individuals may have a pre-existing history of poor adjustment to society (school, work, family) and there may even be a history of prior injury claims (personal injury, workers comp, etc.). Although their complaints also overlap with PCS criteria, they likely have no disability at all (or at least they are not as limited as they present to be).

Diagnostically, these patients are fairly easy to identify for the trained examiner because of their inability to consistently feign meaningful deficits. Clinicians have also become quite adept at identifying these individuals with specific tests designed to measure the honesty of their effort during the assessment. As a result, patients who malinger are generally fairly easy to spot.

Treatment on the other hand is difficult. After all, malingering is a clinical disorder and these patients could conceivably profit from some type of intervention. The problem is that they may not desire to change due to the potential for financial gain. By the same token, few clinicians are willing to treat these individuals and even fewer insurance companies are willing to fund such treatment endeavors.

Co-Morbidity

The question ultimately arises as to whether or not it is possible to suffer two or more of the above noted injuries during the same accident. Certainly, people with mild TBI or PTSD can (and often do) sustain additional cervical-adnexal injuries and have chronic pain but it at least helps to tease apart these disorders and treat each condition separately. There is also some controversy in the literature regarding the co-occurance of mild TBI and PTSD. This however is rare and when it does occur, it is usually due to two sequential events: one event causing TBI and a second event causing PTSD. In these rare instances, treatment should also be sequential. Treat the PTSD first and then address the mild TBI problems. Pharmacology will likely help in these instances and if provided adequate treatment, these patients can usually recover quite well.

In summary, labeling a patient with PCS is similar to telling a sick person they have some type of an infection. What really matters are the specifics of the illness. Therein lies the direction to treatment. With careful evaluation, it is possible to make these finer distinctions and render better care. Collectively, however, PCS as a valuable diagnostic category turns out to be as much myth as it is fact. If you have questions about how these differential diagnoses may relate to you or someone you know, seek consultation with a rehab specialist who can assist you in addressing these issues.

Brain Injury Association of Oklahoma

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